Medial Clavicular Osteophyte

Hindawi Publishing Corporation
Case Reports in Vascular Medicine

Volume 2015, Article ID 723182, 3 pages
http://dx.doi.org/10.1155/2015/723182
Case Report
Medial Clavicular Osteophyte: A Novel Cause of
Paget-Schroetter Syndrome
Keagan Werner-Gibbings and Steven Dubenec
Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, NSW 2006, Australia
Correspondence should be addressed to Keagan Werner-Gibbings; kwer2596@uni.sydney.edu.au
Received 19 December 2014; Accepted 30 March 2015
Academic Editor: Atila Iyisoy
Copyright 2015 K. Werner-Gibbings and S. Dubenec. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Paget-Schroetter syndrome is a form of upper limb deep venous thrombosis usually seen in younger patients in association with
repetitive activities of the affected limb. When occurring in more elderly patients or in those where it is difficult to appreciate
a causative mechanism, other aetiologies should be considered. We present a case in which degenerative osteoarthritis of the
sternoclavicular joint with osteophyte development impinged on the subclavian vein, leading to extensive upper limb thrombosis.
The difficulties in identifying and managing this unusual cause of Paget-Schroetter are presented and discussed.
1. Introduction
Paget-Schroetter Syndrome is a deep venous thrombosis
(DVT) of the subclavian-axillary vein complex usually seen in
association with repetitive upper limb activity [1]. Anatomical
variations that act to narrow the thoracic outlet such as
cervical ribs and hypertrophied musculature are known to
predispose towards the development of this condition. Less
common causative mechanisms such as posterior dislocation
of the clavicular heads and Langers axillary arch have also
been reported. We report a unique case of the investigation
and management of Paget-Schroetter Syndrome caused by a
large clavicular head osteophyte.
2. Case Report
A 69-year-old former competitive rower and active sportsman presented to the emergency department with a 10day history of pain and increasing swelling to his left
arm. His background history included hypertension and
paroxysmal atrial fibrillation. Physical examination revealed
a neurovascularly intact left arm with extensive swelling distal
to the axilla. No other abnormality was detected on physical
examination. The patient was left-handed. Venous duplex
ultrasound demonstrated occlusive thrombus in the left
upper limb venous system involving the proximal subclavian,
axillary and basilic veins, and the brachial veins to the level
of midhumerus. Laboratory testing showed no evidence of a
coagulation disorder.
Contrast venography confirmed thrombus extending
from the brachial vein to the left brachiocephalic vein
(Figure 1). Mechanical thrombectomy (Angiojet, MEDRAD
Inc.) was employed to decrease thrombotic burden in the
affected vessels. Subsequently an infusion catheter was placed
in the left brachiocephalic vein. A urokinase infusion was
initiated through with daily venography demonstrating resolution of thrombus distal to the first rib following 48 hours
of treatment. Angioplasty of the subclavian-axillary system
with a 12 mm balloon demonstrated impingement at the level
of the first rib. CT angiography of the thoracic outlet showed
poor filling of the left upper limb venous system with focal
narrowing of the left subclavian artery as it passed over the
first rib, suspecting the presence of a fibromuscular band of
the first rib causing subclavian vein compression.
Following thrombolysis, the patient underwent a leftsided transaxillary first rib resection to decompress the
thoracic outlet with the aim of subsequently placing a stent
across the affected portion of subclavian vein. During stent
placement, performed 10 days after his first rib resection,
the patients left-sided central veins had again thrombosed,
necessitating further mechanical thrombectomy to restore
patency. A venous stent was then placed at the level of
Figure 1: Venogram of Left subclavian vein demonstrating thrombus extending into the left brachiocephalic vein.
Figure 3: Sagittal view of left subclavian stent impingement.
3. Discussion
Figure 2: Axial view of large osteophytic projection arising from

the posterior surface of the left clavicular head impinging the left
subclavian stent.
venous stenosis with poststenting venography, demonstrating a widely patent vessel. The patient was discharged on oral
anticoagulation therapy.
The patient was symptom-free at his 3-month follow-up;
however, a CT at that time demonstrated compression of the
subclavian vein stent with significant architectural distortion.
The causative mechanism of this impingement was a large
osteophytic projection arising from the posterior surface of
the left clavicular head (Figures 2 and 3). Dedicated imaging
of the sternoclavicular joints bilaterally exposed further signs
of severe arthrosis and posterosuperior joint subluxation,
indicating advanced osteoarthritic degenerative disease of the
joint. The significance of the compression exerted by this large
projection was not appreciated on the initial imaging and was
likely the initiating factor of the primary thrombotic event.
A specialist shoulder surgeon was consulted on the possibility of surgical resection of the osteophytic prominence
to relieve the obstruction. The expert orthopaedic opinion
was that resection of the entire medial segment of clavicle
was the only available course of treatment. This procedure
would necessarily result in a significant functional deficit for
the patient where previously none existed. The decision was
therefore made to treat medically with anticoagulation and
ongoing review. The patient remains symptom-free 6 months
after the initial event.
Effort thrombosis or Paget-Schroetter Syndrome is a form

of upper limb DVT that occurs when strenuous activity
of the upper limb results in subclavian vein endothelial
microtrauma and activation of the coagulation cascade [2].
Anatomical variations that act to narrow the thoracic outlet
such as cervical ribs, fibromuscular bands, and hypertrophied
musculature are well known to exacerbate the development
of Paget-Schroetter syndrome [3]. Less frequent causative
mechanisms such as posterior dislocations of the clavicular
head [4], pseudoarthrosis of the clavicle [5], and Langers
axillary arch [6] have previously been reported as precipitating upper limb DVT. This is the first reported case
of a sternoclavicular osteophyte secondary to osteoarthritis
causing subclavian vein obstruction and upper limb deep
venous thrombosis.
Degenerative osteoarthritis of the sternoclavicular joint
is a relatively common condition, especially in the elderly
population [7], with osteophytic projections being a frequent
part of the pathological process [8]. It is seen more commonly
in active people and extensive rowing experience of the
patient presented in this case was likely a contributing factor
to the development of his degenerative joint changes.
This anatomical variant presents diagnostic and therapeutic challenges. The presence and impact of the osteophytic
projection could not be fully appreciated on initial presentation as extensive thrombus in the vasculature rendered
visualisation of the course and calibre of the subclavian vein
difficult on CT imaging. The significance of the osteophytic
projection and the severe compression it imparted on the
subclavian vein could only be appreciated after surgical
intervention and placement of the radiolucent stent.
The management of this condition, once identified, is
challenging. The accepted treatment for sternoclavicular
arthrosis causing significant pain or functional impairment
is surgical resection of the medial clavicular head, as less
invasive treatment is unlikely to be effective [9, 10]. In
an appropriate management plan in patients with symptomatic sternoclavicular arthrosis refractory to conservative
management, this procedure imparts significant functional
impairment and a substantial impact on quality of life [9]. In

view of the patients active lifestyle, clavicular head resection
was not an appropriate intervention and the decision was
made to continue the treatment conservatively with ongoing
anticoagulation.
4. Conclusion
Paget-Schroetter syndrome is common in younger active
patient groups. When occurring in more elderly patients
other aetiologies such as abnormal anatomical compression
of the subclavian vein should be considered. As seen in this
case, degenerative osteoarthritis with osteophytic development can significantly compress posterior structures and may
not be appreciated until the full course of the subclavian vein
is possible to be visualized.
Disclosure
There has been no duplicate or alternate submission of this
work or any part thereof. All the authors of this paper have
reviewed the document in its entirety and are in agreement
with the structure and content.
Conflict of Interests
There is no conflict of interests or relevant disclosures to
declare.
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Degenerative disease in the temporomandibular, metatarsophalangeal
and sternoclavicular joints: an autopsy study, Acta Odontologica Scandinavica, vol. 34, no. 1, pp. 2332, 1976.
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[9] C. A. Rockwood Jr., G. I. Groh, M. A. Wirth, and F. A.
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The Journal of Bone & Joint SurgeryAmerican Volume, vol. 79,
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[10] A. Pingsmann, T. Patsalis, and I. Michiels, Resection arthroplasty of the sternoclavicular joint for the treatment of primary
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Case Reports in Vascular Medicine

Case Reports in Vascular Medicine

Figure 3: Sagittal view of left subclavian stent impingement.

Figure 2: Axial view of large osteophytic projection arising from

Effort thrombosis or Paget-Schroetter Syndrome is a form

Case Reports in Vascular Medicine

[7] S. Kopp, G. E. Carlsson, T. Hansson, and T. Oberg,

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